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Documenting Medical Necessity for Psychotherapists

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audits

Discharge Summary blanks with lighting

September 30, 2025

Why Your Discharge Summary Matters (More Than You May Think)

A therapist recently called me in a panic. She had gotten an audit letter for a client she discharged over 6 months ago. She wanted to know if an insurance company can do an audit on a client she no longer sees. Yes, they can, and they do. The instructions in the audit letter were clear. She … [Read more...] about Why Your Discharge Summary Matters (More Than You May Think)

Clinical Documentation audits,  clinical documentation,  discharge planning,  discharge summary,  golden thread,  liability protection,  psychotherapy notes,  risk management,  termination

Documentation Wizard mental health clinical documentation expert

February 15, 2023

5 Types of Insurance Reviews

If you’ve ever gotten a letter from a health insurance company and felt your blood pressure spike while you open it, you’re not alone. The fear of being audited can cause as much anxiety as having a suicidal client.  But just like a range in client risk, there is more or less risk involved with … [Read more...] about 5 Types of Insurance Reviews

Passing Audits audits,  compliance,  payer requests,  utilization review

insurance audit therapist

June 6, 2022

Questions & Answers: Audits

Questions & Answers: Audits Therapists aren’t taught clinical documentation in school, leaving them vulnerable to audits and claw backs. The Documentation Wizard is here to help answer some of the most commonly asked questions about audits so you aren’t caught … [Read more...] about Questions & Answers: Audits

Passing Audits audits,  compliance,  documentation,  insurance

how to survive a health insurance audit for psychotherapists

May 7, 2021

How To Survive A Health Insurance Audit

The Insurance Vultures are Circling Insurance companies have recently been conducting audits, like vultures looking for dinner. Especially Medicare. Fight, flight, freeze, or fawn! An audit letter from a health insurance company is enough to send shock waves through your body and make your … [Read more...] about How To Survive A Health Insurance Audit

Passing Audits appeals,  audits,  compliance,  documentation,  insurance,  medical necessity

women reviwing electronic medical record

November 8, 2019

EMRs and EHRs and Online Programs, oh my!

Do psychotherapists need to use EMRs or EHRs for writing clinical notes? The short answer is, “no.”  Not yet. And maybe-not-ever. There are other (better) tools psychotherapists can use for writing clinical notes and documenting medical necessity. Really? Yes! To understand the … [Read more...] about EMRs and EHRs and Online Programs, oh my!

Documenting Mental Health,  EHR,  EMR,  Paper Notes,  Progress Notes,  Psychotherapist Notes audits

Get higher reimbursement rates with hand drawing an upward arrow

June 23, 2019

Documenting Mental Health CPT Code 90837

Many therapists provide a 60 minute session but afraid of triggering an audit, they do not bill for it. We love our work but unless we are independently wealthy, we need to be paid to do it. We don’t get paid for providing psychotherapy. We get paid for our time. Psychotherapy is what we spend our … [Read more...] about Documenting Mental Health CPT Code 90837

Health Insurance (including billing) audits,  billing,  CPT 90837,  medical necessity

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Recent Articles

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  • Why Your Discharge Summary Matters (More Than You May Think)

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